Common Bile Duct Clearance Research Articles

The Nowhere Stone: Unusually Located Intrahepatic Calculi in a Patient with Low Phospholipid-associated Cholelithiasis Syndrome

ABSTRACTIntrahepatic calculi or hepatolithiasis is an uncommon phenomenon which is found in relatively higher rates in eastern Asian countries. Patients usually present with features of cholangitis or intrahepatic abscess and are at risk for developing cholangiocarcinoma. Correct diagnosis and management often pose challenges. A 42-year-old female presented with a history of episodic upper abdominal pain since 8 years. Initial imaging studies showed evidence of biliary calculi, but were confounding in their localization. Magnetic resonance cholangiopancreatography showed two large calculi in the right biliary system proximal to the confluence, along with choledocholithiasis. Endoscopic retrograde cholangiopancreatography and common bile duct clearance were done; however, the patient underwent hepatic sectionectomy as a curative procedure. ABCB4 mutation was detected on DNA analysis and hence aided in making the diagnosis of low phospholipid-associated cholelithiasis. Additional imaging studies are warranted in doubtful cases. Difficult accessibility of the calculi may often limit endoscopic therapeutic options and pave the way for surgical interventions. As there is an increased risk of cholangiocarcinoma in these patients, regular follow-up is essential.

Laparoscopic Intraoperative Choledochoscopic Guided Laser Lithotrypsy, A Rural Hospital's Simple Solution For Difficult Common Blie Duct Stones

Introduction: Proven or suspected common bile duct (CBD) stones require CBD clearance. This can be done by magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC) or Endoscopic retrograde cholangiopancreatography (ERCP) followed by a laparoscopic cholecystectomy (LC), or by a single stage procedure: intraoperative cholangiography (IOC) and/or Laparoscopic CBD exploration (LCBDE) by a choledochoscopy, followed by LC. The latter is our routine approach, since Yoseftal is a rural hospital lacking interventional radiology, gastroenterology or magnetic resonance imaging units. Patients that had difficult CBD stones (DCBDS) ware sent to a regional center, away from their supporting community. We introduced a previously described approach of laparoscopic intraoperative choledochoscopic guided laser lithotrypsy (LCLL) in order to treat DCBDS. Method: We used a Holmium laser in a LCLL approach to treat patients who had DCBDS. We enrolled patients who had a suspected CBD stones and elected to be treated by this approach in our hospital. Result: We treated two patients who suffered from DCBDS by LCLL: both had single stone with a diameter of 1.4cm and 1cm and a CBD diameter of 1.4cm and 1.5 cm. Both operations were without complications, and had an uneventful perioperative course. Conclusion: LCLL is a simple and feasible method for rural hospitals to treat patients who have difficult CBD stones by a single procedure within their community without significant complications.

Multidisciplinary management of Common Bile Duct Stones: A single centre experience of 844 patients over a five and a half year period

Introduction: CBD stone diagnosis and management has deeply changed during the last 30 years, with the inclusion of imaging, like endoscopic ultrasound and magnetic resonance cholangiography endoscopy and laparoscopy. We present our data on the contemporary management of CBD stones. Method: A retrospective study of case records of all patients treated for common bile duct stones from jan 2012 to jun 2017 at our institute was undertaken. Various methods of treatment, both endoscopic and surgical and their complications were detailed. Result: 844 patients treated for CBD stones in a period of 66 months. 418 patients were males and 426 were females. The median age was 56yrs(6-94 yrs). EUS was performed on all patients.Our data showed sensitivity(95.75%) and PPV (95.27%) of EUS over MRI(Sensitivity 93.5%, PPV 95.08%).This was followed by therapeutic ERCP on the same day if EUS was positive for stones. Only sick patients with cholangitis underwent ERCP drainage as primary procedure. Of the 1592 ERCPs performed, 889 were performed for CBD stones. Our Success rate was 89.7%. Surgical Intervention was required in 532 cases. In 386 patients, laparoscopic cholecystectomy was performed within 48 hrs of the ERCP and were discharged home with 3-5 days of hospital stay.There were 35 interval cholecystectomies, 67 laparoscopic CBD explorations and 25 open explorations. Surgical complications were minimal- 3 patients having collection in GB fossa, 1 with port site abscess. Conclusion: This combined use of EUS, ERCP and Laparoscopy results in excellent success rates of common bile duct clearance and near zero mortality over a large series of cases.

Safety and efficacy of laparoscopic versus open surgery in management of common bile duct stones: experience at the Sohag University Hospital, Egypt

Background: Management of common bile duct (CBD) stones includes removal of the gallbladder and clearance of the ductal system which can be achieved through different approaches; endoscopic, laparoscopic or surgical. Objective of this study is to assess the safety, efficacy, technical feasibility and surgical outcomes of laparoscopic common bile duct exploration (LCBDE) versus open surgery in the treatment of patients with cholidocholithiasis.Methods: From June 2015 to December 2017, 120 patients with CBD stones were prospectively treated at Sohag University Hospital, Upper Egypt. Patients were divided into two groups: the first one treated by LCBDE (60 patients), while the other group treated by open surgery (60 patients).Results: The ages of our patients were ranged from 20 to 80 (mean = 40) years, with a female predominance (female/male = 74/46). Patients in the first group were treated by laparoscopic approaches: transcystic approaches in four patients and transcholedochotomy approaches in 56 patients. Choledochoscop was routinely used to detect, extract the stones, in addition to assessment of CBD clearance. The conversion rate was done in two cases. The operative time was 120 (90-220) min, the clearance of CBD stones was achieved in 98.4% of cases (one case of missed stones). Hospital stay was 3 (2-4) days, with no mortality, morbidity rate was 5% including bile leak, and missed stone. The operative time in the second group was 100 (80-180) min, the clearance of CBD stones was achieved in 96.6% of cases (two cases of missed stones). Hospital stay was 8 (5-12) days, with no mortality; the morbidity rate was 15% in the form of wound infection, bile leak, missed stone and ileus.Conclusions: Management of cholidocholithiasis by laparoscopic approach is feasible, effective and safe procedure with good outcome and high success rate.

Laparoendoscopic rendezvous in the treatment of cholecysto-choledocholitiasis: a single series of 200 patients.

Although the ideal management of cholecysto-choledocholitiasis is controversial, the two-stage approach, namely the common bile duct (CBD) clearance through endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy, remains the standard way of management. However, whenever feasible, the one-stage approach, using the so-called "laparoendoscopic rendezvous" (LERV) technique, offers some advantages, mainly reducing the hospital stay and the risk of post-ERCP pancreatitis. The aim of this study was to evaluate the safety and the efficacy of the one-stage approach, and to compare our results with data from available large studies. We reviewed our series of consecutive patients with cholecysto-choledocholitiasis treated by LERV from January 2003, to October 2016. Both elective and emergency cases were included. The primary end-point was the efficacy to obtain the CBD stones clearance. Secondary end-points were morbidity and mortality, operative time, conversion rate, and in-hospital stay. A total of 200 patients underwent a LERV procedure for the intra-operative diagnosis by intra-operative cholangiogram of cholecysto-choledocholitiasis. In 187 patients (93.5%), it was possible to cannulate the cystic duct with the jag-wire. Success rate was 95%. Conversion rate was 3%. The mean operative time was 135min and the mean in-hospital stay was 4 days. 29 (14.5%) were the early complications, six mild pancreatitis. Four patients required re-operation during the hospital stay. 11 patients (5.5%) developed late complications during a median follow-up of 57.7months. Our results confirm that LERV technique is a safe procedure with high success rates for the treatment of cholecysto-choledocholitiasis. The major advantages include the single-stage treatment, the shorter hospital stay, and the lower incidence of post-ERCP pancreatitis.

Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of\xa0a one-stage approach

IntroductionThe timing and optimal method for common bile duct (CBD) clearance and laparoscopic cholecystectomy remains controversial. Several different approaches are available in clinical practice. The current study presents the experience of two European hospitals of simultaneous laparoscopic cholecystectomy (LC) and intra-operative endoscopic retrograde cholangiopacreatography (IO-ERCP) done by surgeons.MethodsRetrospective analysis of all consecutive patients subjected to LC + IO-ERCP during their index admission between 4/2014 and 9/2016. Data accrued included patient demographics, laboratory markers, operation time (min) reported as mean (± SD) and hospital length of stay (LOS) reported as median (lower quartile, upper quartile).ResultsDuring the 29-month study, a total of 201 consecutive LC + IO-ERCPs were performed. The mean age of patients was 55 ± 19 years and 67% were female. The mean intervention time was 105 ± 44 min. The total LOS was 4 (3, 7) days and the post-operative LOS was 2 (1, 3) days. A total of 6 (3%) patients experienced post-interventional pancreatitis and two (1%) patients suffered a Strasberg type A bile leak. All patients were successfully discharged.ConclusionSimultaneous LC + IO-ERCP is associated with few complications. Further studies investigating cost-benefit and patient satisfaction are warranted.

Laparoscopic-Assisted Transgastric ERCP: A Single-Institution Experience

Background Laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is used for treatment in patients after Roux-en-Y gastric bypass (RYGB), where transoral access to the biliary tree is not possible. We describe our technique and experience with this procedure. Methods Electronic medical record search was performed from September 2012 to January 2016, identifying patients who underwent LAERCP per operative records. Charts were reviewed for demographic, clinical, and outcomes data. Results Sixteen patients were identified. Average time since bypass was 6.9 years, and length of stay was 3.7 days. Five patients underwent simultaneous cholecystectomy. Eleven patients, or 43%, had cholecystectomy more than 2 years previously. ERCP with sphincterotomy was completed in 15 of 16 patients (94%). Our technique involves access to the bypassed stomach via a laparoscopically placed 15 mm port. We observed one major complication of post-ERCP necrotizing pancreatitis. No minor complications nor mortalities were seen in our series. Conclusion Biliary obstruction can occur many years after RYGB and cholecystectomy. Our findings suggest that RYGB patients may be at a higher risk of primary CBD stone formation. LAERCP is a reliable option for common bile duct (CBD) clearance; our technique of LAERCP is technically simple and associated with low complication rate, making it appealing to surgeons not trained in advanced laparoscopy.

ERCP stent as a nidus for CBD stone: post cholecystectomy status

Obstruction of common bile duct due to a ‘Forgotten stent’ causing stone formation is a rare entity, which is usually associated with cholangitis. A much rarer presentation is our case with an ERCP stent forming a nidus for stone formation in the common bile duct without any evidence of cholangitis or bile duct obstruction. A 66-year-old female patient with a previous history of laparoscopic cholecystectomy and common bile duct stenting done 2 years back presented with vague abdominal pain, nausea and vomiting without features of jaundice or cholangitis. She was diagnosed on imaging as a case of choledocholithiasis with two stents in the common bile duct. A failed ERCP to extract the stent and relieve obstruction necessitated open choledochotomy, stents removal, common bile duct clearance and choledochoduodenostomy. The rarity of this patient with an ERCP acting as a nidus for common bile duct stones without evidence of obstruction or cholangitis is something to be documented. Although rare, these complications must always be considered and considered a possibility due to which post-operative and post-endoscopic follow up, regular check-ups and timely removal of the stents is necessary to avoid unnecessary complications or a need for repeat procedures and surgery that results in greater morbidity.

Cost-analysis and effectiveness of one-stage laparoscopic versus two-stage endolaparoscopic management of cholecystocholedocholithiasis: a retrospective cohort study

BackgroundOne–stage laparoscopic common bile duct (CBD) stone clearance and laparoscopic cholecystectomy (LCBDE+LC) for cholecystocholedocholithiasis ( CCL) can be performed with similar short and long-term outcomes than two-stage endoscopic retrograde cholangiography followed by subsequent LC (ERCP+LC). This study examined retrospectively the outcome and hospital costs of one-stage versus two-stage treatment of CBD stones.MethodsFrom January 1999 and December 2014, 217 consecutive, elective patients underwent one-stage (LCBDE + LC ) or two-stage (ERCP + subsequent LC ) treatment for CBD stones. The data from the one-stage management was collected prospectively, and from the two-stage management retrospectively. The main measure of outcome was hospital costs, with the success of one-stage versus two-stage management, postoperative morbidity and postoperative stay as secondary outcome measures.ResultsOne-stage laparoscopic transcystic management was the least costly option compared to laparoscopic one-stage transductal approach (TC 5455€ versus TD 9364, p < 0.001) or two-stage management (6913 €, p = 0.02). Overall success rate of primary intervention (including conversions to open surgery) for CBD stone clearance was 96.9%, 97.0% and 98.3% after transcystic one-stage, transductal one-stage and two-stage approach, p = 0.79. Postoperative morbidity was 15.5% versus 7.5%, p = 0.64, and postoperative hospital stay median 2 days (IQR 2–5) versus 4.5 days ( IQR 3–7), p < 0.001 in the one-stage and two-stage management groups.ConclusionsOur study shows that laparoscopic one-stage transcystic management of CCL results in high rate of CBD clearance, fewer procedures per patient, shorter hospital and lower costs than the two-stage management. Therefore the one-stage transcystic management seems to be an attractive strategy for the treatment of CCL depending on local resources and surgical expertise .

Tu1487 Direct Peroral Cholangioscopy in the Evaluation of Common Bile Duct Clearance After Endoscopic Management of Difficult Biliary Stones: Preliminary Results of a Pilot Study

Tu1487 Direct Peroral Cholangioscopy in the Evaluation of Common Bile Duct Clearance After Endoscopic Management of Difficult Biliary Stones: Preliminary Results of a Pilot Study

Preliminary experience with laparoscopic common bile duct exploration

BackgroundHerein we present our experience with laparoscopic common bile duct exploration (LCBDE) in managing common bile duct stones.MethodsData of 129 consecutive patients who underwent laparoscopic cholecystectomy (LC) and LCBDE done at our institutes from April 2011 through June 2016 were prospectively recorded and retrospectively reviewed.ResultsSince 2011, 3012 laparoscopic cholecystectomy were performed at our institutes, intraoperative cholangiogram (IOC) was done in 295 (9.8%) patients which detected choledocholithiasis in 129 (4.3%) of them. LCBDE was successful to clear the common bile duct (CBD) in 123/129 (95.4%). Six patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) because of incomplete CBD clearance (4 cases), symptomatic stenosed papilla (2 cases). LCBDE was performed in 103 patients via trans-cystic approach and choledochotomy one in 26 patients. In the choledochotomy group, seven patients had primary closure of the CBD, CBD was closed over T-tube in nine patients whereas the remaining 10 patients the CBD was closed over antegrade inserted stent. The median time of hospital stay was 4 (range; 1–15) days. No patients showed retained CBD stones with mean follow up was 9 ± 3.4 months.ConclusionLCBDE is a safe and cost effective option for CBD stones in short-term outcome and can be performed provided proper laparoscopic expertise and facilities are available.

Is it time to write obituary for open choledocholithotomy in the present era of endoscopic management? Outcome of surgery for failed endoscopic extraction, retrospective study

Background: Between 05 to 20 percent of patients undergoing cholecystectomy for gallstones, have choledocholithiasis. Treatment of the common bile duct (CBD) stones can be conducted as open cholecystectomy and open CBD exploration or laparoscopic cholecystectomy plus laparoscopic CBD exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy or sphincteroplasty (papillary dilatation) for CBD clearance. The merits and demerits of individual techniques are yet to be settled.Methods: We reviewed the outcome of patients operated at our centre after failed endoscopic clearance of CBD stones. Over a period of 03 years, total 2145 laparoscopic/open cholecystectomies were performed at our institute. In the same time period, 14 patients (06 males and 08 females) presented with choledocholithiasis after failed ERCP extraction (median age 59 years, range 29-62 years). All the patients had undergone ERCP and ± sphincterotomy/sphincteroplasty with failed clearance. None of the patient had undergone a cholecystectomy previously.Results: We performed open choledocholithotomy with T-tube drainage plus cholecystectomy in all the patients. There were no deaths and only one major complication. Surgery resulted in complete duct clearance in 93% of patients.Conclusions: Open surgery can be performed safely and effectively in patients with retained bile duct stones and surgery can be offered as primary modality of treatment over combined endoscopic management after appropriated patient selection.

How can recovery be enhanced after single-stage laparoscopic management of CBD stones? Endoscopic treatment versus laparoscopic surgery

BackgroundSingle-stage management of CBD stones comprises simultaneous common bile duct (CBD) clearance and cholecystectomy. The CBD can be cleared by using endoscopic treatment (ET) or laparoscopic surgery (LS) alone. AimsTo determine the most rapid recovery after the single-stage laparoscopic management of CBD stones. MethodsPatients with CBD stones treated at either of two centers (one performing ET only and one performing LS only for single-stage treatment) were included. The primary endpoint was “the textbook outcome”. ResultsThe feasibility rate was 74% for ET and 100% for LS (p≤0.001). The proportion of cases with the textbook outcome was higher in the ET group than in the LS-only group (73% vs. 10%; p<0.001). The CBD clearance rate was similar in the ET and LS-only groups (100% vs. 96.6%, respectively; p=0.17). The overall morbidity rate was lower in the ET group than in the LS-only group (23% vs. 29%, p=0.05). Conclusion and relevanceBoth ET and LS are feasible, safe and effective for clearance of the CBD. ET was better than LS in terms of a less frequent requirement for drainage and a shorter length of hospital stay. LS was associated with a shorter operating time.

OC.11.6: Direct Peroral Cholangioscopy in the Evaluation of Common Bile Duct Clearance after Endoscopic Management of Difficult Biliary Stones: Preliminary Results of a Pilot Study

OC.11.6: Direct Peroral Cholangioscopy in the Evaluation of Common Bile Duct Clearance after Endoscopic Management of Difficult Biliary Stones: Preliminary Results of a Pilot Study

Laparoendoscopic rendezvous may be an effective alternative to a failed preoperative endoscopic retrograde cholangiopancreatography in patients with cholecystocholedocholithiasis.

Background:Endoscopic retrograde cholangiopancreatography (ERCP), followed by laparoscopic cholecystectomy (LC), remains the standard way of management for patients with cholecystocholedocholithiasis. Laparoendoscopic rendezvous (LERV), a combined procedure for removing the gallbladder laparoscopically and clearing the common bile duct (CBD) endoscopically at the same time, could be an attractive alternative. The aim of this study was to compare LERV with classic ERCP in patients with cholecystocholedocholithiasis.Methods:886 patients with cholecystocholedocholithiasis were treated either with the LERV technique (90 patients), or with the 2-stage approach, which includes preoperative ERCP followed by LC (796 patients). The primary endpoint was any difference in the success of CBD cannulation and clearance; secondary endpoints were the detection of differences in morbidity (especially post-ERCP pancreatitis [PEP]), and the feasibility of the two approaches.Results:Successful cannulation of the CBD was more frequent with conventional ERCP compared with the LERV technique (89.8% vs. 75.5%, P=0.0001). LERV appears to be as effective as conventional ERCP for complete CBD clearance (85.5% vs. 82.8%, P<0.1). None of the patients in the LERV group had an episode of clinical PEP, whereas in the conventional ERCP group there were 23 episodes of PEP and one death. The median amylase level was higher in patients undergoing conventional ERCP group compared to patients in LERV group.Conclusion:Classic ERCP has a higher rate of successful CBD cannulation and a similar rate of CBD clearance compared to LERV.

Common bile duct clearance of stones by open surgery, laparoscopic surgery, and endoscopic approaches (comparative study)

Background and aim of the work Around 10–18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment can be provided as open cholecystectomy plus open CBD exploration, laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE), or precholecystectomy or postcholecystectomy endoscopic retrograde cholangio-pancreatography (ERCP) in two stages for CBD clearance. The aim of this study is to compare the CBD clearance rate by each procedure in a well-equipped tertiary center. Patients and methods A total of 250 patients with choledocholithiasis were included from the General Surgery Department, Sohag and Assiut University Hospitals, and managed randomly by either conventional surgery, endoscopic, or laparoscopic procedures. Results The ages of our patients ranged from 20 to 60 years (mean=40 years), with a slight female predominance (1.6 : 1); most of them presented with calcular obstruction (54.3%). However, there were also other presentations such as colic, cholangitis, or accidental discovery in 14.3, 10, and 21.5%, respectively. Patients were categorized randomly into three groups: group I included 100 patients (40%) who were treated by open choledocholithotomy and T-tube insertion; the operative time was 90 (60–180) min, with the success rate of the attempted procedures reaching 100%, and CBD clearance of stones was achieved in 95% of cases (five cases of missed stones). Hospital stay was 8 (5–12) days, with no mortality, and morbidity rate reached 15% in the form of wound infection, bile leak, and missed stone. The patient could return to work after 2 weeks (12–20 days). Group II included 100 patients (40%) treated by endoscopic sphincterotomy; basket extraction was performed in 45%, balloon in 25%, the combined maneuver in 15%, and mechanical lithotripsy in 13%, with failure of the technique in two cases (2%); the duration of the procedure was about 30 (20–45) min, with a success rate of attempted procedures of 98%, and CBD clearance of stones was achieved by 100%, with no mortality; the morbidity rate was 9% in the form of cholangitis (3%) and mild pancreatitis with hyperamylasemia (6%). The period of hospital stay was 1 (1–2) days and the patient returned to work after 3 (2–5) days. Group III included 50 patients (20%) treated by laparoscopic approaches: transcystic approaches in five cases and transcholedochotomy approaches in 45 cases. Choledochoscopic exploration was performed in almost all cases (45 cases) to detect, extract the stones, and test CBD clearance, and there was conversion to open techniques in one case. The time needed for this procedure was 123 (70–292) min, with CBD clearance of stones in 96% (two cases of missed stone), with no mortality, and a morbidity rate of about 10% in the form of mild hyperamylasemia, fever, and missed stone. The period of hospital stay was 3.2 (2–4) days, with return to work after 7 (5–10) days. Conclusion Both ERCP/LC and LCBDE were highly effective in CBD clearance, and equal in terms of the overall cost and patient acceptance. However, the overall duration of hospitalization was shorter for LCBDE with elimination of the potential risks of ERCP-associated pancreatitis, further procedures, and anesthesia risks. It is feasible, cost-effective, and ultimately should be available for most patients in each specialized center.

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones.

AIMTo evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease.METHODSAll patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients’ files.RESULTSA total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 ± 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 ± 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 ± 6.9 mm vs 7.2 ± 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 ± 6.3 mm vs 12.0 ± 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence.CONCLUSIONBile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Endoscopic ultrasound of bile duct hydatid membrane

Background:Hepatic hydatid cyst rupture into the bile ducts (intrabiliary rupture) is the most common and serious complication of hepatic hydatid disease, occurring in 2%–42% of cases. Intrabiliary rupture (IBR) can be diagnosed by ultrasonography, computerized tomography, or magnetic resonance imaging.Methods:Transabdominal ultrasonography showed a 3.2 cm × 3.4 cm cyst in the right lobe of the liver, dilatation of the biliary system up to the lower end of the common bile duct (CBD), and biliary sludge in the gallbladder. Linear EUS was performed before endoscopic retrograde cholangiopancreatography (ERCP) to know the etiology of cholangitis.Results:Linear EUS from stomach revealed multiple curvilinear, leaflet-shaped, rounded, and irregular structures within dilated CBD and common hepatic duct. These structures were hyperechoic, multilayered, with intervening anechoic areas without acoustic shadowing indicating membranous structures folded many times. The structures were floating inside the CBD suggestive of hydatid membranes. Cholangiogram revealed a dilated CBD with multiple irregular filling defects formed by the hydatid membranes. ERCP with biliary sphincterotomy and balloon sweeping resulted in CBD clearance with expulsion of the multiple bile stained and whitish hydatid membranes. There was a significant improvement in clinical condition after ERCP. Follow-up USG after 2 weeks revealed normal CBD with decreased size of liver cyst.Conclusions:EUS by demonstrating the presence of mobile hydatid membranes or cyst-like material may be useful when other imaging modalities are inconclusive or unavailable in IBR. ERCP is both diagnostic and therapeutic in IBR, with removal of hydatid membranes relieving jaundice and cholangitis.

Single-Session Treatment of Cholecysto-Choledocholithiasis: Totally Laparoscopic &amp;lt;i&amp;gt;versus&amp;lt;/i&amp;gt; Laparo-Endoscopic

Background: This study details Assiut and South Valley universities experience in treating combined gall bladder and common bile duct stones in a single session, either with Endoscopic Retrograde Cholangio-Pancreatography (ERCP) for Common Bile Duct (CBD) stone extraction followed by laparoscopic cholecystectomy (LC), or totally laparoscopic treatment. Patients and methods: In this prospective randomized study, 46 consecutive patients with confirmed cholecysto-choledocholithiasis were randomized to 2 groups. Group (A) included 24 patients treated with single-session ERCP for CBD stone extraction and laparoscopic cholecystectomy [ERCP-LC]. Group (B) included 22 patients treated with laparoscopic CBD exploration and laparoscopic cholecystectomy [LCBDE-LC]. Demographic data, operative time, CBD clearance success rate, short term complications and duration of hospital stay were recorded. Results: Patients included 28 females and 18 males with mean age of 42.1 ±‏ 12.1 years (range 17 – 71 years). In 22/24 patients (91.7%) ERCP-LC was done successfully. Mean operative time was 105 ± 19.1 minutes (50-150 min.). No intra-operative complications occurred. Early post-operative complications occurred in 3 patients (12.5%). Mean hospital stay was 2.1 ± 0. 91 days (1-6 days). In the other group, LCBDE-LC was performed successfully in 22/22 patients (100%). Mean operative time was 145 ± 23 minutes (100-180 min.). Minor intra-operative complications (bleeding) occurred in 2/22 cases (9%). Minor early post-operative complications (bile leak, ileus, bleeding) occurred in 4/22 patients (18%). Mean hospital stay was 2.8 ± 0.83 days (2-7 days). Conclusion: Single session ERCP-LC and LCBDE-LC procedures for management of cholecysto-choledocholithiasis are feasible, safe, and effective and have comparable outcome regarding success rate, peri-operative complications. ERCP-LC has statistically significant less operative time and less hospital stay.

Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution.

Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage. Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression. We found stones (n=388) or bile sludge (n=71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128min in the first 250 LCBDEs, and this decreased to 103min in the second 250 LCBDEs (P=0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P=0.0005), whereas T-tube placement (2 vs 6%; P=0.0225) and transcystic approach (7 vs 12%; P=0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR)=9.87; P=0.007) and failure in stone clearance (RR=11.88; P=0.024) as significant risk factors. Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.